Retrospective analysis of CD4 trends at district levels in South Africa between 2013 and 2023

Abstract

Background: South Africa has the largest HIV epidemic globally. Despite the scale-up of antiretroviral therapy, people living with HIV still present with CD4 ≤ 200 cells/µL because of possible treatment interruptions and/or late presentation.
Objectives: This study assessed the proportion of CD4 specimens with counts ≤ 200 cells/µL by health district, comparing 2013 to 2023.
Method: This cross-sectional study analysed laboratory data. Annual test volumes, median CD4 and the percentage of specimens with a count ≤ 200 cells/µL were reported. The difference in the median CD4 between 2013 and 2023 was calculated. No de-duplication was possible because of the absence of unique identifiers.
Results: Data are reported for 5 821 932 specimens, with a significant decline in absolute numbers, while the percentage of specimens with a count ≤ 200 cells/µL declined by 0.4%. The median CD4 increased from 396 cells/µL in 2013 to 465 cells/µL by 2023. Between 2013 and 2023, eight districts showed a decrease in the median CD4, while 44 reported an increase ranging from 2 cells/µL (Sedibeng) to 192 cells/µL (uThukela). A percentage point reduction for counts ≤ 200 cells/µL between 2013 and 2023 was reported for 23 districts (44.2%), while 29 (55.8%) showed a percentage point increase.
Conclusion: Despite an upward trend in the national specimen-level CD4 count median over time, unacceptable levels of CD4 counts ≤ 200 cells/µL persisted. The analysis provides important insight into district burden of advanced HIV disease which warrants national attention and further investigation.